The Affordable Care Act originally sought make health insurance more accessible in two ways: through a new online markplace that offers federal subsidies, and with a federally-subsidized Medicaid expansion. A Supreme Court ruling allowed states to choose whether or not to expand Medicaid, and Maine is one of 26 states that has opted out. It's creating a coverage gap, where an estimated 25,000 Mainers earn too much to be on Medicaid, but too little to qualify for a subsidy under the Affordable Care Act. Patty Wight has more.

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Mainers Caught in ACA 'Coverage Gap'

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Jerry Robichaud is a book seller. He's 62, and his income is less than the federal poverty level of $11,400 dollars. For a little more than 10 years, Robichaud has received health coverage through MaineCare, the state Medicaid program.

Because of state cuts to the program, that's about to change. "I got the notice a couple weeks ago that it was going to shut off December 31st," he says.

Robichaud says what also hurts is that he doesn't qualify for subsidies under the Affordable Care Act. So, he can't afford coverage. "If anything happens and you need medical help, what am I supposed to do, you know?" he says.

It's situations like Robichaud's that highlight the need for Medicaid expansion, says Jessa Barnard of the Maine Medical Association. For the past decade, her organization has supported across-the-board access to health care.

"We know that, currently in the United States, you need health insurance or health coverage of some sort to access health care in a meaningful way," she says. "And so we support everybody having coverage so that they can access health care, and especially so they can access preventative benefits and primary care services, and get the care that they need when they need it."

Proponents also cite financial reasons to expand Medicaid. The federal government covers 100 percent of the expansion through 2016, then tapers to 90 percent by 2020. Sara Gagne Holmes of the group Maine Equal Justice says even though Maine will eventually need to chip in some money, this is a deal the state can't refuse.

"Expanding Medicaid would allow Maine to draw down federal funds on programs that it currently funds with all state dollars," she says. "We believe those savings could be put into the Mediciad savings account to be used to pay the Maine percentage later on. So yes, we believe that, overall, there are net savings to the Medicaid system by accepting the federal funds."

But whether Maine would truly save money by expanding Medicaid is the million dollar question. According to Department of Health and Human Services Commissioner Mary Mayhew, it's actually a $100 million question. She says that's how much expansion will cost the state once the federal match drops off.

"The price tag for the state of expanding in the out-years in excess of $100 million needs to be evaluated against other significant priorities for the state's MaineCare program," Mayhew says.

Mayhew says Maine is already struggling to keep up with its MaineCare commitments. As one example, she points to the waiting list for individuals with intellectual and developmental disabilities to receive certain services. And when she looks to the future, Mayhew sees Maine's aging demographics, and additional pressures on the Medicaid system.

"There are other challenges to the Medicaid program that are also being lost in the discussion: reimbursement rates to providers, in order to ensure that we have an effective network of providers throughout the state, and in particular in rural areas," she says.

In other states, concerns have been raised that not enough doctors accept Medicaid to meet the demands of an influx of patients. Jessa Barnard of the Maine Medical Association says that's not a concern in Maine. As for the federal reimbursement rate, it is low - about 75 cents for every dollar spent.

But Jeff Austin of the Maine Hospital Association says some reimbursement is better than nothing. Plus, he says, Maine hospitals are already in the midst of a 10-year, $900 million cut in Medicare reimbursements. The cuts are to help finance the Affordable Care Act.

"So we've already experienced the pain of the federal cuts," Austin says, "and so we need to experience some of the off-setting benefit of Medicaid expansion."

Austin says it's important for Maine to consider the financial implications of expanding Medicaid, but he believes the state can cover the costs. Studies by the Kaiser Family Foundation and The Urban Institute have found that Maine would ultimately save money.

Still, these are all projections. There is no definitive answer as to whether expanding Medicaid will take a bite out of the state budget. University of Southern Maine Public Health Professor Andy Coburn says the way he sees it, whether Maine accepts federal dollars to expand Medicaid or not, the cost to care for those who would be covered won't go away.

"You know, the question is: Where do you want the money to come from?" Coburn says. "Do you want it to come out of premiums that we all pay through employer-based insurance? Or do we want to pay it through a direct revenue - tax-based revenue - source, such as the state and the federal governments?"

DHHS Commissioner Mary Mayhew says Maine needs to explore more flexible options. Some states, such as Arkansas and Iowa, are devising plans that, instead of expanding Medicaid, provide large subsidies for the poor to buy insurance on the Marketplace.

Sara Gagne Holmes, of Maine Equal Justice Partners, says Maine has the power to resolve the issue of the Medicaid coverage gap, whether it's through expanding Medicaid, or a compromise option. But timing will be critical, since the 100 percent federal match only lasts through 2016.